24-1107m Medical Policies - September 2024

Date: 10/16/24

Review the most recent changes to new and existing medical policies for procedures and services

The medical policies listed in this update were approved by Centene’s Corporate Clinical Policy Committee and/or Health Net’s Medical Advisory Council (MAC) for September 2024. For a complete description of the background, criteria, references, and coding implications for the medical policies, go to Health Net Medical Policies.

Purpose of medical policies

Medical policies offer guidelines to help determine medical necessity for certain procedures, equipment and services. They are not intended to give medical advice or tell providers how to practice. If required, providers must get prior authorization before services are given.

Medical policies vs. member contract

All services must be medically needed unless the member’s benefit plan coverage document states otherwise. That document defines member benefits in addition to eligibility requirements, and coverage exclusions and limits.

• For Medi-Cal plans, appropriate coverage guidelines take precedence over these plan policies and must be applied first.
• If legal or regulatory mandates apply, they may override medical policy.
• If there are any conflicts between medical policy guidelines and related member benefits contract language, the benefits contract will apply.

Updated Policies

CPT Copyright 2024 American Medical Association. All rights reserved. CPT^® is a registered trademark of the American Medical Association. 

Policy number and name	Change
CP.MP.108 – Allogeneic Hematopoietic Cell Transplant for Sickle Cell Disease	Added note at end of Description regarding criteria related to Casgevy®. Reformatted all notes in policy description. Reformatted Criteria I.A. to specify ‘One of the following…’
CP.MP.180 – Implantable Hypoglossal Nerve Stimulation	Added Criteria II. regarding drug induced sleep endoscopy (DISE) being medically necessary when completed to evaluate the appropriateness of a hypoglossal nerve stimulation device. CPT code “42975” added.
CP.MP.202 – Orthognathic Surgery	Updated Criteria I.A.1.b. from greater than 4 mm to 4 mm or greater. Updated Criteria I.A.2.c. to include irritation of buccal or lingual soft tissues of the opposing arch. Added clarifying language to Criteria I.A.3.b.

 

Retired Policies

Policy number	Name
CP.MP.53	Ferriscan R2-MRI
HNCA.CP.MP.456	Ultrafiltration for Heart Failure

 

Additional information

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone or through the Health Net provider portal.
Behavioral health providers can call 844-966-0298.

Line of business	Phone number	Email
Ambetter from Health Net IFP Ambetter PPO	844-463-8188	email
Ambetter HMO	888-926-2164	email
Health Net Employer Group HMO, POS, & PPO	800-641-7761	email
Medi-Cal (including CS and ECM providers)	800-675-6110	N/A
Behavioral Health providers	844-966-0298	N/A

 

This information applies to Physicians, Participating Physician Groups (PPGs), and Behavioral Health Providers.

For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Molina, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.